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HX64074722 
RA644.T7  C73        What  has  the  demonst 


What  Has  The  Demonstration  Done  ? 
Should  It  Be  Continued  ? 


REPORT  OF  THE 


COMMITTEE   ON   APPRAISAL 

FOR  THE 

FRAMINGHAM  COMMUNITY  HEALTH  AND 
TUBERCULOSIS  DEMONSTRATION 


COMMUNITY  HEALTH  STATION 

FRAMINGHAM,  MASS. 

OCTOBER,   1919 


RAk^-n 


C73 


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What   Has  The   Demonstration  Done  ? 
Should  It  Be  Continued  ? 


REPORT  OF  THE 

COMMITTEE   ON   APPRAISAL 

FOR  THE 

FRAMINGHAM  COMMUNITY  HEALTH  AND 
TUBERCULOSIS  DEMONSTRATION 


COMMUNITY  HEALTH  STATION 

FRAMINGHAM,  MASS. 

OCTOBER,    1919 


C13 


CONTENTS 

Page 

Committees  and  Staff 3 

Foreword 5 

Appraisal  Committee  Recommendations 7 

Key-note  Sentences 8 

The  Report 11 

Introduction 11 

General  Impressions 12 

The  Practicability  of  Tuberculosis  Control       ...  14 

The  Advisability  of  Continuing 15 

Recommendations  as  to  Continuance 17 

A  Five- Year  Extension 17 

Coordination  of  Local  Health  Agencies      .      .      .      .  18 


FRAMINGHAM  COMMUNITY  HEALTH  AND 
TUBERCULOSIS  DEMONSTRATION 


APPRAISAL  COMMITTEE 


Dr.  Allan  J.  McLaughlin,  Chairman     .  U.  S.  Public  Health  Service. 

*Prof.  C.-E.  A.  Wlnslow,  Secretary       .     .  Yale  University,  New  Haven,  Conn. 

Dr.  Edgar  T.  Sydenstricker     .     .      .      .  U.  S.  Public  Health  Service. 

Dr.  Charles  V.  Chapin Health  Commissioner,  Providence,  R.  I. 

Dr.  Victor  G.  Heiser Rockefeller  Foundation,  N.  Y.  City. 

Miss  Helen  R.  Stewart National  Public  Health  Nursing  Association. 

Mr.  George  J.  Nelbach State  Charities  Aid  Association,  New  York. 

Dr.  Emery  R.  Hayhurst State  Department  of  Health,  Ohio. 

Dr.  Thomas  A.  Storey American  School  Hygiene  Association. 

Dr.  Samuel  McCllntock  Hamill   .     .      .  University  of  Pennsylvania. 

Dr.  Louis  Hamman Johns  Hopkins  Medical  School. 

Dr.  Lawrason  Brown Trudeau  Sanatorium,  Saranac  Lake,  N.  Y. 

Dr.  H.  R.  M.  Landis Phipps  Institute,  Philadelphia,  Pa. 


NATIONAL  COMMITTEE 


Dr.  Edward  R.  Baldwin,  Chairman       .     .  Saranac  Lake,  N.  Y. 

Dr.  Charles  J.  Hatfield,  Secretary       .     .  New  York  City. 

Dr.  Lee  K.  Frankel New  York  City. 

Dr.  Victor  C.  Vaughan Ann  Arbor,  Mich. 

Mr.  Homer  Folks New  York  City. 

Dr.  Arthur  K.  Stone Framingham,  Mass. 

Dr.  Eugene  R.  Kelley Boston,  Mass. 

Dr.  Stephen  J.  Maher New  Haven,  Conn. 

Dr.  William  Charles  White     ....  Pittsburgh,  Pa. 

Dr.  Victor  Safford Boston,  Mass. 

Dr.  F.  C.  Smith Washington,  D.  C. 

Dr.  Enos  H.  Bigelow Framingham,  Mass. 

Mr.  Henry  S.  Dennison Framingham,  Mass. 

Mr.  Theo  F.  Rice Framingham,  Mass. 


EXECUTIVE  STAFF 


Donald  B.  Armstrong,  M.D.,  Executive  Officer 
P.  Challis  Bartlett,  M.D.,  Chief  Medical  Examiner 


♦Professor  Winslow  has  recently  accepted  an  appointment  on  the  National  Committee. 


On  May  3,  1916,  the  conception  of  a  community  tuberculosis  experiment 
was  first  outlined  in  a  letter  received  by  the  National  Tuberculosis  Associa- 
tion from  Dr.  Lee  K.  Frankel,  Third  Vice-President  of  the  Metropolitan  Life 
Insurance  Company.  In  this  communication  Dr.  Frankel  discussed  tuber- 
culosis work  in  general,  and  stated  that,  in  his  belief,  much  might  be  accom- 
plished toward  the  eradication  of  tuberculosis  through  an  intensive  experiment 
aimed  at  the  control  of  this  disease.  In  offering  the  financial  aid  of  the 
Metropolitan  Life  Insurance  Company  in  such  an  experiment  Dr.  Frankel 
stated : 

"To  this  end  we  are  prepared  to  place  at  the  disposal  of  the  National 
Association  for  the  Study  and  Prevention  of  Tuberculosis  the  sum  of  one 
hundred  thousand  dollars  ($100,000.)  for  the  purpose  of  conducting  a  com- 
munity experiment  over  a  period  of  three  years  in  the  control  of  tuberculosis." 

In  outlining  the  fundamentals  of  such  an  experiment  and  demonstration 
Dr.  Frankel  indicated  that  stress  should  be  placed  upon  periodic  medical  ex- 
aminations for  all  members  of  the  community,  medical  and  nursing  care  for  all 
tuberculosis  cases,  adequate  dispensary  and  institutional  treatment,  the 
cooperation  of  local  and  state  agencies,  etc. 

This  offer  was  accepted  immediately  by  the  National  Tuberculosis  Asso- 
ciation, and  the  energies  of  that  association  have  been  devoted  to  the  direc- 
tion of  the  experiment  since  its  actual  initiation  on  January  1,  1917.  Pre- 
vious to  that  date  considerable  time  was  spent  in  the  selection  of  an  appro- 
priate community,  Framingham,  Mass.  being  finally  chosen  for  the  work. 

As  indicated  above,  the  Framingham  Community  Health  and  Tuber- 
culosis Demonstration  was  originally  planned  for  a  three-year  period.  On 
this  basis  the  Demonstration  would  have  ended  on  January  1,  1920.  In 
view  of  the  fact  that  many  phases  of  the  program  would  inevitably  have 
been  unfinished  on  that  date,  the  National  Tuberculosis  Association  took 
steps  through  the  National  Committee  in  charge  of  the  Framingham  work, 
during  the  summer  of  1919,  to  meet  the  following  points  of  inquiry: 

1.  How  much  has  the  Experiment  or  Demonstration  accomplished 
thus  far? 

2.  In  what  measure  has  the  work  approached  an  answer  to  the  problem 
originally  set,  as  reflected  by  the  essentials  briefly  referred  to  above? 

3.  Would  an  extension  of  time  for  the  Demonstration  be  justifiable? 
Two  principal  methods  were  used  to  answer  these  inquiries.     The  first 

was  the  appointment  of  a  Progress  Committee,  serving  as  a  Sub-Committee 


of  the  National  Committee,  to  study  these  problems,  and  to  report  their  find- 
ings to  the  National  Tuberculosis  Association.  The  second  was  the  creation 
of  an  outside  Appraisal  Committee,  to  render  an  impartial  judgment  upon 
these  fundamental  questions. 

Through  the  cooperation  of  Surgeon  General  Rupert  Blue  of  the  United 
States  Public  Health  Service,  such  an  Appraisal  Committee  was  appointed, 
to  make  an  unprejudiced  and  scientific  analysis  of  the  Framingham  work. 
The  members  of  this  Committee  have  visited  Framingham,  two  formal  com- 
mittee meetings  have  been  held,  and  the  report  of  the  committee,  as  sub- 
mitted to  Surgeon  General  Blue,  follows  in  this  publication. 

After  approval  by  the  Appraisal  Committee,  this  report  was  passed  upon 
by  Surgeon  General  Rupert  Blue,  by  the  Progress  Committee  on  the  Fram- 
ingham work,  by  the  National  Committee  in  charge  of  the  Demonstration, 
by  the  Executive  Committee  of  the  National  Tuberculosis  Association,  and 
finally  by  the  Board  of  Directors  of  the  Metropolitan  Life  Insurance  Com- 
pany, with  the  result  that  the  Appraisal  Committee  recommendations  and 
general  plan  for  the  extension  were  approved,  with  only  minor  changes  as  to 
budget  suggestions,  and  an  additional  appropriation  made  by  the  Metropol- 
itan Life  Insurance  Company  to  carry  on. the  work  for  the  year  1920. 

The  Health  Demonstration  staff  wishes  to  take  this  opportunity,  both 
for  itself  and  for  the  National  Tuberculosis  Association,  to  extend  its  appre- 
ciation and  thanks  to  the  Appraisal  Committee  for  their  thorough  and 
imaginative  approach  to  the  problem  and  for  their  invaluable  suggestions. 
The  Demonstration  officers  are  particularly  grateful  for  the  work  of  Professor 
C.-E.  A.  Winslow  as  Secretary  of  the  Committee,  to  whose  broad  knowledge 
and  keen  analytical  vision,  the  excellence  of  the  report  is  in  great  measure  due. 


SUMMARY  OF  CONCLUSIONS  AND 
RECOMMENDATIONS 


Surgeon  General  Rupert  Blue, 
U.  S.  Public  Health  Service, 
Washington,  D.  C. 

1.  Your  committee  feels  that  the  work  of  the  Framingham  Community 
Health  and  Tuberculosis  Demonstration  during  the  past  three  years  is  worthy 
of  high  praise.  It  has  organized  and  carried  out  a  community  plan  for  the 
control  of  tuberculosis  along  the  lines  indicated  by  the  best  modern  scientific 
knowledge.  It  has  given  us  the  first  reliable  information  as  to  the  actual 
amount  of  tuberculosis  present  in  a  typical  American  community;  and  in  the 
organization  of  a  tuberculosis  consultation  service  it  has  made  a  contribution 
of  the  first  magnitude  to  the  machinery  of  public  health  protection.  In 
addition,  it  has  stimulated  the  development  of  the  general  public  health 
campaign  in  Framingham  to  a  degree  that  goes  far  to  realize  the  highest 
ideals  of  modern  sanitary  science. 

2.  The  Demonstration  has  not  furnished  an  answer  to  the  primary 
question  as  to  the  practicability  of  the  control  of  tuberculosis,  because  the 
period  of  three  years  was  necessarily  too  short  to  make  a  conclusive  answer 
to  this  question  possible.  The  results  thus  far  obtained  are  as  promising  as 
could  be  expected,  but  an  extension  of  the  work  for  a  period  of  five  years 
more  will  be  necessary  in  order  to  insure  with  reasonable  certainty  a  satis- 
factory answer  to  this  question. 

3.  Your  committee,  therefore,  recommend  that  a  further  appropriation 
of  $100,000.00  should,  if  possible,  be  obtained  for  the  continuance  of  the 
Demonstration  experiment  along  the  general  lines  indicated  in  the  body  of  its 
report. 

Committee  on  Appraisal: 

Allan  J.  McLaughlin,  Chairman, 

Lawrason  Brown,  H.  R.  M.  Landis, 

Charles  V.  Chapin,  George  J.  Nelbach, 

S.  McC.  Hamtll,  Helena  R.  Stewart, 

Louis  Hamman,  Thomas  A.  Storey, 

Emery  R.  Hayhurst,  Edgar  T.  Sydenstricker, 

Victor  G.  Reiser,  C.-E.  A.  Winslow,  Secretary. 


KEY-NOTE  SENTENCES 


As  To  Results: 


1.     The  Extent  of  Tuberculosis. 


The  first  step,  a  determination  of  the  actual  prevalence  of  tuberculosis 
infection,  has  been  accomplished  with  a  high  degree  of  success,  giving  us  for 
the  first  time  a  fairly  complete  picture  of  the  amount  of  tuberculosis  actually 
existing  in  a  typical  American  community. 

2.     The  Consultation  Service. 

The  most  important  of  all  the  practical  contributions  made  by  the 
Demonstration  is  the  working  out  of  a  plan  for  medical  consultation  service, 
which  is  clearly  the  most  promising  means  yet  devised  for  securing  a  rea- 
sonably complete  knowledge  of  the  amount  of  tuberculosis  existing  in  a  given 
community.  The  consultation  service  plan  has  attracted  wide  attention 
throughout  the  country. 

3.  Tuberculosis  Treatment. 

The  machinery  adopted  for  the  treatment  of  cases  of  tuberculosis  after 
they  have  been  discovered  has  been  modelled  along  generally  accepted  lines. 
The  work  has  been  accomplished  efficiently  and  successfully. 

4.  Standards  of  Diagnosis. 

The  officers  of  the  Demonstration  have  prepared  a  scheme  of  diagnostic 
standards  for  tuberculosis  which  has  attracted  wide  attention. 

5.     Death  Certification  Analysis. 

The  careful  analysis  of  death  certificates,  showing  that  the  actual  deaths 
from  tuberculosis  in  Framingham  were  22  per  cent,  in  excess  of  the  reported 
deaths  from  this  disease,  also  constitutes  a  valuable  contribution. 

6.     Sanitary  Studies. 

From  the  standpoint  of  general  environmental  causes  effecting  the  spread 
and  development  of  tuberculosis,  the  staff  of  the  Demonstration  has  conducted 
valuable  studies  of  schools,  factories,  and  municipal  health  conditions. 

8 


7.     General  Sickness  Prevalence. 

The  medical  examination  drives  have  yielded  some  of  the  most  complete 
data  in  regard  to  the  prevalence  of  disease  of  all  sorts  in  a  random  section  of 
the  population  that  have  ever  been  collected  in  this  country. 

8.     The  Tuberculosis  Death  Rate. 

From  the  standpoint  of  mortality,  the  tuberculosis  death  rate  has  fallen 
from  93  per  100,000  in  1917  to  a  rate  corresponding  to  76  for  the  first  five 
months  of  1919.  This  is  an  encouraging  showing,  in  view  of  the  fact  that 
the  tuberculosis  death  rate  in  similar  Massachusetts  communities,  has  in 
general  materially  increased. 

As  To  Framingham: 

9.     The  Town's  Response. 

The  town  of  Framingham  has  responded  with  vision  and  effectiveness 
to  the  remarkable  opportunities  offered  by  the  establishment  of  the  Demon- 
stration. The  local  Board  of  Health,  the  School  Committee,  the  Civic  League, 
and  many  of  the  employers  of  labor,  have  met  the  challenge  to  make  Fram- 
ingham the  model  "Health  Town"  with  constructive  responses  of  a  high  order. 

10.     Local  Health  Development. 

Even  more  important  from  the  practical  standpoint  has  been  the  notable 
development  of  public  health  work  in  Framingham  along  a  wide  variety  of 
lines. 

11.     The  Health  and  School  Departments. 

The  local  health  department  has  grown  to  be  a  strong  and  effective  one, 
and  the  system  of  medical  inspection  of  school  children,  organized  under  the 
Department  of  Education,  represents  one  of  the  best  examples  of  such  service 
to  be  found  in  the  United  States. 

12.     The  Community  Benefited. 

It  seems  clear  that  if  the  Framingham  Demonstration  should  cease  on 
January  1,  1920,  the  local  community  will  have  benefited  materially  and 
many  important  contributions  will  have  been  made  to  the  practical  control 
of  tuberculosis. 

13.     Need  for  Local  Coordination. 

It  seems  to  us  if  the  Demonstration  is  to  be  continued  that  it  might  be  of 
service  to  organize  in  Framingham  a  Health  Council  which  would  include  the 


Health  Officer,  or  a  Board  of  Health  representative  as  Chairman,  with  repre- 
sentatives of  the  School  Committee,  the  Civic  League,  the  Framingham  Hos- 
pital, the  Red  Cross,  the  medical  society,  and  the  Demonstration, — this 
council  to  serve  as  a  clearing-house  for  the  coordination  of  health  activities 
and  the  planning  of  the  most  effective  public  health  machinery  for  the  com- 
munity as  a  whole.  We  deem  it  to  be  of  great  importance  to  transfer  the 
work  to  them  (the  local  agencies)  as  rapidly  as  possible. 

In  General: 

14.     The  Foundations  Laid. 

The  foundation  has  been  well  laid;  a  program  for  the  control  of  tuber- 
culosis by  early  diagnosis  and  hygienic  care  has  been  organized  on  ideal  lines ; 
local  sentiment  both  in  the  medical  and  lay  circles  has  been  successfully 
developed  in  support  of  the  campaign ;  and  all  conditions  are  favorable  to  its 
success. 

15.     Continuation  Vital. 

These  statistical  calculations  have  led  us  to  the  conclusion  that  the  Fram- 
ingham Demonstration  should  be  continued  for  a  period  of  at  least  five  years 
in  order  to  render  the  attainment  of  definite  results  of  reasonable  certainty. 
It  would  furnish  for  the  first  time  a  definitely  established  working  program 
for  the  practical  control  of  tuberculosis. 

16.     Appreciation. 

We  desire  to  express  our  warm  appreciation  of  the  many  courtesies  ex- 
tended to  us  by  the  staff,  and  the  opportunities  offered  to  form  a  sound  judg- 
ment as  to  the  character  of  the  work,  through  conference  with  local  individ- 
uals and  agencies,  both  inside  and  outside  the  Demonstration  circle. 


10 


Report  of  Committee  on  Appraisal 

FOR  THE 

Framingham  Community  Health  and  Tuberculosis 

Demonstration 


Surgeon  General  Rupert  Blue, 
U.  S.  Public  Health  Service, 
Washington,  D.  C. 

Dear  General  Blue: — 

1.     Introduction. 

The  Committee  on  Appraisal  for  the  Framingham  Community  Health 
and  Tuberculosis  Demonstration  was  appointed  by  you  last  May  to  investi- 
gate the  work  that  has  been  done  in  Framingham  under  the  direction  of  the 
National  Tuberculosis  Association,  and  to  report  upon  the  results  so  far 
attained  and  the  desirability  of  continuing  the  work  beyond  the  three  years 
originally  planned. 

The  purpose  of  the  Framingham  Demonstration,  as  we  understand  it, 
was  to  apply  the  most  complete  program  for  the  control  of  tuberculosis  indi-  purpose 

OP*   THF 

cated  by  present  scientific  knowledge,  with  the  view  to  determine  whether  demonstra- 
and  in  what  degree  it  is  possible  with  the  information  at  our  disposal  to 
obtain  definite  and  tangible  results  from  such  a  campaign. 

Your  committee  has  held  two  formal  meetings,  at  Atlantic  City  on  June 
8th,  and  at  Framingham  on  August  14th,  and  between  these  dates  most  of 
the  members  of  the  committee  have  visited  Framingham  and  made  a  per- 
sonal study  of  the  work  on  the  ground,  while  full  and  extensive  documentary 
data  in  regard  to  the  Demonstration  have  been  furnished  us  by  Dr.  D.  B. 
Armstrong,  its  Executive  Officer.  We  desire  at  this  point  to  express  our 
warm  appreciation  of  the  many  courtesies  extended  to  us  by  Dr.  Armstrong 
and  his  staff,  and  the  opportunities  offered  to  form  a  sound  judgment  as  to 
the  character  of  the  work,  through  conference  with  local  individuals  and 
agencies  both  inside  and  outside  the  Demonstration  circle. 

11 


2.     General  Impressions  of  the  Framingham  Community  Health  and 
Tuberculosis  Demonstration. 

The  officers  in  charge  of  the  Demonstration  have  accepted  what  appears 
at  present  the  soundest  current  viewpoint,  that  the  most  effective  practical 
procedure  for  the  control  of  tuberculosis  lies  in  the  development  of  machinery 
for  its  early  detection  and  for  the  hygienic  care  of  individuals  affected  or 
threatened  with  the  disease, — while  at  the  same  time  taking  such  opportu- 
the  extent     nities  as  offer  to  minimize  the  spread  of  the  infectious  agent.     The  first  step 
tuberculosis  a^ong  this  line  must  be  a  determination  of  the  actual  prevalence  of  tuber- 
determined     cuious  infection,  and  this  end  has  been  accomplished  with  a  high  degree  of 
success  by  the  organization  of  medical  examination  drives,  by  the  organiza- 
tion of  a  tuberculosis  consultation  service,  and  by  the  establishment  of  infant, 
school,  industrial  and  other  clinics.     Efforts  along  this  line  have  been  strik- 
ingly successful  in  giving  us  for  the  first  time  a  fairly  complete  picture  of 
the  amount  of  tuberculosis  actually  existing  in  a  typical  American  commu- 
nity. 

The  conclusion  that  in  the  medical  examination  drives  nearly  one  per 
cent,  of  the  persons  examined  were  suffering  from  active  tuberculosis  while 
somewhat  over  one  per  cent,  more  were  arrested  cases,  is  an  important  one. 
This  finding,  if  assumed  to  be  representative  of  the  whole  community  and 
compared  with  the  death  rate  for  the  town,  would  indicate  a  ratio  of  9  or  10 
active  cases  during  the  year  to  one  reported  death.  The  best  way  to  esti- 
mate this  factor  would  in  our  judgment  be  to  compare  the  number  of  active 
cases  under  observation  during  a  given  year  with  the  number  of  deaths 
occurring  among  that  group  of  cases.  The  actual  experience  of  the  Demon- 
casesAforVE  strati°n  nas  Deen  tnat  tw0  hospital  beds  have  been  required  for  each  reported 
one  death  death;  but  the  period  is  too  short  and  the  number  too  small  to  warrant  far- 
reaching  deductions.  Furthermore,  it  should  be  noted  that  it  would  have 
been  difficult  to  fill  this  indicated  ratio  of  beds  without  the  effective  machinery 
for  locating  cases,  at  the  disposal  of  the  Demonstration.  On  a  basis  of  the 
active  advanced  cases  in  which  the  need  for  hospitalization  was  most  acute, 
the  ratio  indicated  by  the  Framingham  experience  would  be  nearer  one  bed 
to  each  reported  case.  The  careful  analysis  of  death  certificates  showing 
that  the  actual  deaths  from  tuberculosis  in  Framingham  were  22  per  cent,  in 
excess  of  the  reported  deaths  from  this  disease  also  constitutes  a  valuable 
contribution,  although  the  small  number  of  cases  involved  makes  it  impossible 
to  apply  this  conclusion  in  any  general  way. 

In  connection  with  the  problem  of  diagnosis,  the  officers  of  the  Demon- 
stration have  prepared  a  scheme  of  diagnostic  standards  for  tuberculosis 
which  has  attracted  wide  attention. 
consultation         The  most  imPortant  of  a11  the  Poetical  contributions  made  by   the 
5ESX2SLS?*      Demonstration  is  the  working  out  of  a  plan  for  medical  consultation  service 

IMPORTANT  °  . 

contribution  wnich  is  clearly  the  most  promising  means  yet  devised  for  securing  a  reason- 

12 


ably  complete  knowledge  of  the  amount  of  tuberculosis  existing  in  a  given 
community.  This  work  has  been  carried  on  by  Dr.  P.  C.  Bartlett  with 
admirable  scientific  skill  and  exceptional  tact  and  judgment.  The  physicians 
of  the  community  almost  without  exception  avail  themselves  freely  of  this 
service  and  aside  from  the  direct  results  in  the  detection  of  early  and  doubtful 
cases,  the  stimulating  effect  upon  the  local  medical  profession  constitutes  an 
invaluable  service  to  the  cause  of  public  health  in  Framingham.  The  con- 
sultation service  plan  has  attracted  wide  attention  throughout  the  country 
'and  under  the  auspices  of  the  State  Department  of  Health  and  the  State 
Tuberculosis  League  such  a  service  has  been  offered  for  three  months  in  the 
Cape  Cod  district  of  Massachusetts  with  great  success.  The  plan  is  already 
in  operation,  or  is  proposed,  in  sections  of  Illinois,  New  York,  Ohio,  Oklahoma, 
Vermont  and  Wisconsin. 

The  success  of  this  organized  campaign  for  the  discovery  of  tuberculosis 
is  indicated  by  the  fact  that  nearly  200  cases  are  now  under  observation  in 
Framingham  as  compared  with  27  at  the  beginning  of  the  Demonstration,  decrease  in 
and  it  is  particularly  encouraging  to  note  that  during  the  first  year  42  percASESNCED 
cent,  of  the  new  reported  cases  were  of  an  advanced  type,  while  in  the  second 
year  only  16  per  cent,  of  the  cases  were  advanced,  and  in  the  first  five  months 
of  1919  only  23  per  cent. 

The  machinery  adopted  for  the  treatment  of  cases  of  tuberculosis  after 
they  have  been  discovered  has  been  modelled  along  generally  accepted  lines, 
involving  sanatorium  treatment,  or  hygienic  advice  furnished  through  the 
service  of  a  public  health  nurse,  as  circumstances  may  dictate  in  the  individual  efficient 
case.  There  has  been  nothing  here  that  is  particularly  novel,  but  the  work 
has  been  accomplished  efficiently  and  successfully  along  the  lines  indicated  by 
the  best  current  practice. 

In  view  of  the  great  difficulty  of  securing  adequate  sanitary  control  under 
such  home  conditions  as  are  frequently  met  with,  particularly  in  the  later 
stages  of  the  disease,  we  desire  to  emphasize  the  importance  of  extending 
facilities  for  local  hospital  treatment.  It  is  our  opinion  that  such  treatment 
can  be  applied  most  effectively  by  the  development  of  hospital  facilities 
within  convenient  street  car  radius  of  the  homes  of  the  patients. 

From  the  standpoint  of  the  general  environmental  causes  effecting  the 
spread  and  development  of  tuberculosis,  the  staff  of  the  Demonstration  has 
conducted  valuable  studies  of  schools,  factories,  and  municipal  health  condi- 
tions, and  the  general  situation  as  it  affects  tuberculosis  seems  to  be  as  satis- 
factory as  could  reasonably  be  expected.  Only  two  important  points  which  VALUABLE 
directly  concern  the  control  of  tuberculosis  appear  so  far  not  to  have  been  sanitary 
covered, — the  establishment  of  a  central  pasteurizing  station  for  the  milk 
supply  of  the  community  and  the  organization  of  a  comprehensive  system  of 
industrial  clinics  for  the  smaller  manufacturing  plants.  Both  of  these  meas- 
ures have  been  contemplated  by  the  officers  of  the  Demonstration,  and  it 
seems  to  us  most  important  that  these  two  gaps  should  be  filled. 

13 


dataFonANT  Believing  that  the  control  of  tuberculosis  is  closely  connected  with  all 

sickness  conditions  which  tend  to  build  up  the  health  of  the  community,  the  officers 

of  the  Demonstration  have  devoted  a  considerable  share  of  their  attention  to 
the  formulation  of  a  general  health  program  beyond  the  specific  field  of  tuber- 
culosis itself.  The  medical  examination  drives  have  yielded  some  of  the  most 
complete  data  in  regard  to  the  prevalence  of  disease  of  alksorts  in  a  random 
section  of  the  population  that  have  ever  been  collected  in  this  country.  These 
data  are  of  much  value  as  indicating  the  prevalence  of  such  conditions  and 
development  tne  unit  costs  involved  in  such  examinations.  Even  more  important  from 
healtt^  tne  practical  standpoint  has  been  the  notable  development  of  public  health 

activities  work  in  Framingham  along  a  wide  variety  of  lines,  which  has  resulted  directly 
or  indirectly  from  the  activities  of  the  Demonstration.  The  amount  of  money 
spent  for  health  protection  in  Framingham  has  been  increased  during  the  life 
of  the  Demonstration  from  39c.  to  $2.00  per  capita.  Half  of  the  latter  sum 
is  contributed  from  public  sources  by  the  Department  of  Health  and  the 
Department  of  Education,  and  the  other  half  from  private  sources  through  the 
Civic  League,  and  the  industrial  clinics  established  by  public-spirited  manu- 
facturers. The  local  Health  Department  has  grown  to  be  a  strong  and  effec- 
tive one  and  the  system  of  medical  inspection  of  school  children  organized 
under  the  Department  of  Education  represents  one  of  the  best  examples  of 
such  service. to  be  found  in  the  United  States.  Machinery  for  protecting  the 
health  of  infants  and  children  of  the  pre-school  age  has  been  worked  out 
under  the  auspices  of  the  Civic  League,  and  with  the  advances  made  during 
the  present  summer  includes  four  infant  clinics,  and  a  pre-school  clinic.  On 
the  whole,  this  work  seems  somewhat  less  satisfactory  than  the  other  phases 
of  the  local  health  movement,  but  a  foundation  has  been  laid  upon  which 
progress  will  no  doubt  be  made  in  the  future. 

The  work  of  the  Demonstration  has  been  extended  in  certain  directions 
somewhat  beyond  the  field  of  definite  public  health  activity,  and  the  Com- 
mittee on  Appraisal  feels  that  such  appropriations  as  those  made  for  the  Com- 
munity House  of  the  Civic  League  and  for  the  maintenance  of  the  Day  Camp 
for  subnormal  children  might  well  be  discontinued  in  the  near  future.  -Yalu- 
i  able  as  these  enterprises  are,  it  seems  to  us  unlikely  that  they  will  yield 
tangible  results  in  the  saving  of  life. 

3.     Conclusions  to  be  Drawn  from  the  Demonstration  in  Regard  to  the 
Practicability  of  the  Control  of  Tuberculosis. 

The  object  of  the  gift  made  by  the  Metropolitan  Life  Insurance  Company 
to  the  National  Tuberculosis  Association  was  not  as  we  understand  it,  pri- 
marily to  benefit  Framingham  or  any  other  local  community,  but  to  deter- 
mine the  practicability  of  the  control  of  tuberculosis  by  the  full  application 
of  the  best  known  methods.  The  really  important  question  before  your  com- 
mittee is  not,  therefore,  the  extent  to  which  Framingham  has  benefited  by  the 

14 


development  of  an  admirable  scheme  of  local  health  organization,  but  the  Rf  £J"  ££TE 
degree  to  which  this  organization  has  been  effective  in  controlling  tuberculosis. 
Success  along  this  line  might  obviously  be  measured  in  two  ways,  by  a  de- 
crease in  new  cases,  or  by  a  decrease  in  the  tuberculosis  mortality.  With 
the  progress  of  the  Demonstration  and  the  improvement  of  machinery  for 
finding  early  cases,  the  recorded  morbidity  at  first  materially  increased,  but 
it  is  interesting  to  notice  that  during  the  first  five  months  of  1919  only  40 
new  cases  came  to  light,  as  against  5  5  new  cases  for  the  corresponding  months 
of  1918.  Obviously,  however,  no  conclusions  can  be  drawn  from  this  isolated 
comparison.  From  the  standpoint  of  mortality,  the  tuberculosis  death  rate 
(after  eliminating  non-residents,  and  adding  deaths  of  residents  occurring  out- 
side of  the  town)  has  fallen  from  93  per  100,000  in  1917  to  79  in  1918,  and 
to  a  rate  corresponding  to  76  for  the  first  five  months  of  1919.  This  is  an 
encouraging  showing  (in  view  of  the  fact  that  the  tuberculosis  death  rate  in 
similar  Massachusetts  communities  has  in  general  materially  increased) ;  but 
again  the  period  is  so  short  and  the  actual  number  of  deaths  so  small  that  no 
reliable  conclusions  can  be  drawn. 

The  member  of  your  committee  representing  statistics  (E.  T.  S.)  has 
prepared  a  computation  of  the  probable  errors  involved  in  the  problem  and 
concludes  after  fitting  the  rates  for  1907-1916  to  the  curve  of  probable  error, 
and  allowing  for  the  mean  error  in  any  given  rate  projected  for  1919-1923, 
that  in  order jtojvaj;raiit^ reasonably  safe  conclusions. -one  or  the  other  of  the 
following  combinations  of  tuberculosis  death  rates  must  be  reached  during 
the  latter  period. 

A  rate  of  30  or  less  for  any  1  year 

A  rate  of  45  or  less  for  any  2  years 

A  rate  of  60  or  less  for  any  3  years 

A  rate  of  75  or  less  for  any  4  years 

A  rate  of  90  or  less  for  all  5  years. 

It  is  obvious  that  rates  between  70  and  80  for  1918  and  1919  cannot 
possibly  be  considered  as  significant,  and  it  could  scarcely  have  been  expected 
in  dealing  with  a  disease  of  the  nature  of  tuberculosis  that  any  conclusive 
results  could  be  reached  in  a  period  so  short  as  three  years. 

4.     Conclusions  in  Regard  to  the  Advisability  of  Continuing  the 
Framingham  Demonstration. 

It  seems  clear  that  if  the  Framingham  Demonstration  should  cease  on 
January  1,   1920,  the  local  community  will  have  benefited  materially  and 
many  important  contributions  will  have  been  made  to  the  practical  control  benefit  to 
of  tuberculosis;  but  that  the  main  question  for  which  the  Demonstration  was  community 
endowed  will  remain  unanswered.     In  the  judgment  of  your  committee  this 
would  be  a  most  unfortunate  contingency.     Our  best  authorities  on  tuber- 

15 


DEMONSTRA- 
TION  WILL 
ANSWER 
VITAL 
QUESTIONS 


RACE   STOCK 
FINDINGS 

IMPORTANT 


culosis  have  been  subject  during  the  past  few  years  to  a  growing  skepticism 
in  regard  to  the  adequacy  of  methods  which  have  been  advocated  for  the 
control  of  this  disease  and  have  turned  eagerly  to  the  Framingham  Demon- 
stration as  the  first  real  opportunity  to  set  their  doubts  at  rest.  If  the 
Experiment  should  be  abandoned  at  this  time  it  would  be  necessary  to  begin 
all  over  again  somewhere  else,  for  a  test  of  the  best  methods  now  available 
is  absolutely  essential  for  future  progress  in  this  field. 

If  on  the  other  hand  it  should  be  possible  to  continue  the  Demonstra- 
tion for  a  sufficient  period  to  yield  results  of  statistical  accuracy,  your  com- 
mittee feels  confident  that  the  question  as  to.  the  soundness  of  the  current 
anti-tuberculosis  program  will  be  definitely  answered  one  way  or  the  other. 
The  foundation  has  been  well  laid;  a  program  for  the  control  of  tuberculosis 
by  early  diagnosis  and  hygienic  care  has  been  organized  on  ideal  lines;  local 
sentiment  both  in  medical  and  lay  circles  has  been  successfully  developed  in 
support  of  the  campaign;  and  all  conditions  are  favorable  to  its  success. 
Given  a  sufficient  period  for  the  continuance  of  the  Demonstration  and  for 
the  study  of  the  results  obtained,  both  morbidity  and  mortality  records  should 
furnish  a  clear  answer  to  the  question  of  whether  or  not  such  a  program  is 
effective. 

In  addition  to  the  fundamental  conclusion  as  to  the  practicability  of  the 
control  of  tuberculosis  by  the  methods  used  in  Framingham,  a  continuation 
of  the  Demonstration  should  throw  important  light  upon  the  theoretic  factors 
which  contribute  to  the  development  of  tuberculosis  as  a  disease,  and  should 
therefore  make  it  possible  to  modify  our  program  along  more  purposeful  lines 
in  the  future.  The  investigations  made  at  Framingham  have  as  yet  led  to  no 
far-reaching  conclusions  in  regard  to  these  factors.  The  most  suggestive  point 
that  has  been  brought  out  is  perhaps  the  variation  in  disease  incidence  among 
different  race  stocks.  The  combination  of  a  very  high  proportion  of  tuber- 
culin reactions  with  a  low  mortality  among  Italians  and  the  precisely  opposite 
condition  among  persons  of  Irish  race  stock  is  of  considerable  significance. 
The  study  of  the  subsequent  history  of  the  large  number  of  arrested  cases 
now  under  the  observation  of  the  Demonstration  constitute,  in  itself,  an 
invaluable  opportunity  to  determine  some  of  the  factors  which  convert  latent 
into  active  disease. 

In  the  continuation  of  the  work  of  the  Demonstration,  we  would  urge 
that  special  attention  be  paid  to  the  intensive  study  of  environmental  condi- 
tions, in  the  home,  the  factory,  and  the  community,  with  a  view  to  throwing 
more  light  than  has  yet  been  obtained  upon  the  possible  effect  of  each  condi- 
tion upon  the  spread  of  tuberculous  infection  and  the  development  of  active 
disease.  We  are  inclined  to  believe  that  the  detailed  study  of  even  a  few  hun- 
dred cases  should  yield  results  of  real  value  in  this  connection; — if  correlated 
with  observation  of  the  environmental  conditions  surrounding  a  properly 
selected  control  group  of  families  free  from  tuberculosis. 


16 


5.     Recommendations  in  Regard  to  the  Continuance  of  the 
Demonstration  in  the  Future. 

The  statistical  calculations  cited  above  have  led  us  to  the  conclusion  that FIVE  years 

.  ,  EXTENSION 

the  Framingham  Demonstration  should  be  continued  for  a  period  of  at  least  necessary 
five  years  in  order  to  render  the  attainment  of  definite  results  of  reasonable 
certainty.  It  is,  of  course,  possible  that  the  prolongation  of  the  Demonstra- 
tion experiment  through  1922  might  be  accompanied  by  a  tuberculosis  death 
rate  of  60  or  less  for  all  of  the  three  years  involved,  but  since  a  death  rate  of 
60  corresponds  to  only  12  deaths,  it  is  obvious  that  a  chance  combination  of 
circumstances  might  easily  interfere  with  such  a  result.  In  this  contingency 
we  should  once  more  face  the  possibility  that  a  large  sum  of  money  had  been 
spent  without  the  attainment  of  the  primary  object  in  view.  The  effect  of 
such  an  experiment  should  be  cumulative,  and  each  year  added  to  its  life 
greatly  increases  the  chances  of  ultimate  success.  A  five-year  period  should, 
we  believe,  yield  results  reasonably  certain  to  answer  "the  question  as  to  the 
practicability  of  the  control  of  tuberculosis.  If  successful,  it  would  furnish 
for  the  first  time  a  definitely  established  working  program  for  the  practical 
control  of  tuberculosis.  If  unsuccessful,  it  would  indicate  with  equal  clear- 
ness the  need  for  the  adoption  of  measures  of  a  different  sort  from  those  that 
have  recently  been  recommended  as  adequate  and  necessary. 

6.     Suggested  Plan  for  a  Five-Year  Extension  of  the 
Framingham  Demonstration. 

In  planning  for  a  continuance  of  the  Framingham  Demonstration  for  the 
purposes  indicated  in  the  preceding  paragraphs,  it  seems  to  your  committee 
best  to  limit  the  work  somewhat  strictly  to  the  definite  problem  of  tuber- 
culosis, and  to  plan  for  no  new  work  that  does  not  directly  bear  upon  the 
fundamental  questions  involved.     It  might  seem  desirable   to  continue  a  JjJPjJJfJJJ*1* 
grant  of  $2,000  to  the  Civic  League  for  its  general  public  health  work  for  a  ^sential 
period  of  one  year,  but  this  should,  in  our  judgment,  cease  after  1920,  and 
we  feel  that  the  wisdom  of  continuing  to  maintain  the  Day  Camp  as  a  part 
of  the  Demonstration  activity  is  distinctly  problematical.     On  the  other  hand, 
an  appropriation  for  the  development  of  industrial  clinics  in  the  smaller  man- 
ufacturing plants  for  a  period  of  at  least  two  years  seems  to  us  important  as 
a  part  of  the  anti- tuberculosis  program;  and  we  feel  that  any  plan  made 
should  provide  for  one  more  general  medical  examination  drive  which  might 
profitably  be  conducted  in  1923,  leaving  1924  free  for  the  analysis  and  diges- 
tion of  the  results  of  the  experiment  as  a  whole.     The  re-examination  of 
individuals  already  examined  in  previous  drives  should  prove  particularly $100000 ^ 
significant  as  a  measure  of  the  effect  of  an  educational  campaign  such  as  that  ^fo^ OPRIA" 
conducted  by  the  Demonstration.     On  this  basis  we  have  prepared  a  tenta-  recommended 
tive  budget,  indicating  the  general  lines  along  which  a  second  appropriation 
of  $100,000.00  might  profitably  be  spent. 

17 


The  budget*  calls  for  annual  expenditures  as  follows: 

1920 $24,600.00 

1921 21,600.00 

1922 18,800.00 

1923 21,700.00* 

1924 13,300.00 

Total $100,000.00 


FURTHER 
RESEARCH 


While  an  appropriation  of  $100,000.00  should  ensure  the  successful  com- 
pletion of  the  primary  experiment,  it  may  be  pointed  out  that  there  are  excep- 
tional opportunities  for  special  research  in  connection  with  tuberculosis,  along 
such  lines  as  the  accumulation  of  an  extensive  series  of  radiographs  of  contact 
cases,  the  intensive  study  of  the  relation  of  race  and  occupation  and  home 
environment  to  tuberculosis,  the  study  of  nutrition  as  a  predisposing  factor 
in  tuberculosis,  and  the  like.  Additional  appropriations  for  research  along 
such  lines  could  be  expended  with  excellent  results  at  Framingham  or  else- 
where. It  must  be  remembered  that  even  if  the  measures  used  at  Framing- 
ham  should  prove  definitely  successful,  they  would  presumably  require  to  be 
simplified  and  made  more  economical  for  general  use;  and  the  application  of 
research  funds  in  any  direction  that  may  lead  to  such  simplification  is  earn- 
estly to  be  desired. 


TOWN'S 

RESPONSE 

ADMIRABLE 


7.     Coordination  of  Existing  Health  Agencies  as  a  Factor  in  the 
Success  of  the  Framingham  Demonstration. 

In  the  main,  the  town  of  Framingham  has  responded  with  vision  and 
effectiveness  to  the  remarkable  opportunities  offered  by  the  establishment  of 
the  Demonstration.  The  local  Board  of  Health,  the  School  Committee,  the 
Civic  League,  and  many  of  the  employers  of  labor  have  met  the  challenge  to 
make  Framingham  the  model  "Health  Town"  with  constructive  responses  of 
a  high  order.  The  work  of  these  various  agencies  has  not,  however,  so  far 
as  we  can  judge,  always  been  coordinated  as  closely  as  might  be  desirable. 
The  Framingham  Hospital  which  directs  the  district  nursing  service  of  the 
community  might  play  a  more  active  part  in  the  general  health  campaign 
than  is  the  case  at  present,  and  the  great  possibilities  of  service  latent  in  the 
local  Red  Cross  organization  have  not  been  fully  utilized. 
local  It  seems  to  us  if  the  Demonstration  is  to  be  continued  that  it  might  be 

tion  through  of  service  to  organize  in  Framingham  a  Health  Council  which  would  include 

HEALTH 

COUNCIL  

*The  proposed  annual  appropriations  were  classified  according  to  medical,  nursing,  research, 
office  and  other  expenses,  and  are  not  given  in  detail  here.  This  budget  was  in  fact  some- 
what modified  by  the  National  Tuberculosis  Association  committees,  the  major  expenses 
being  concentrated  into  an  extension  period  of  three  years  for  intensive  work,  with  a 
smaller  appropriation  for  an  additional  two-year  period  for  subsequent  observation. 

18 


TRANSFER 


the  Health  Officer  or  a  Board  of  Health  representative  as  Chairman,  with 
representatives  of  the  School  Committee,  the  Civic  League,  the  Framingham 
Hospital,  the  Red  Cross,  the  medical  society,  and  the  Demonstration, — this 
council  to  serve  as  a  clearing-house  for  the  coordination  of  health  activities 
and  the  planning  of  the  most  effective  public  health  machinery  for  the  com- 
munity as  a  whole. 

It  is  obvious  that  in  order  to  be  of  general  application,  the  method  of 
control  used  at  Framingham  must  be  susceptible  of  execution  by  existing  local  J^SJV^  T0 
health  agencies  and  we  deem  it  to  be  of  great  importance  to  enlist  the  active  agencies 
cooperation  of  the  Health  Department,  the  hospital,  and  civic  bodies,  and  to 
transfer  the  work  to  them  as  rapidly  as  possible;  although  it  seems  clear  that 
the  observation  of  results  as  regards  tuberculosis  should  until  1924  remain  in 
the  hands  of  the  officers  of  the  Demonstration.  Ultimately  a  fairly  complete 
degree  of  consolidation  should  be  attained,  particularly  in  regard  to  the 
public  health  nursing  service.  Infant  welfare  nursing,  school  nursing,  tuber- 
culosis nursing,  communicable  disease  nursing  and  general  visiting  nursing 
might,  with  advantage,  be  combined  under  the  direction  of  a  nursing  director 
of  training  and  experience. 


19 


PQT  TJIXTDT  A       TTXTTT7'T7<'D  CiTfTiTr      T  TT)T»  A  TlTTTiCt 

DUE  DATE 


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Printed 
in  USA 


COLUMBIA  UNIVERSITY  LIBRARIES 


0022314270 


Ann^x 


RA644.T7  073 

Committee  on  appraisal  for  the 
Framingham  community  health  and 

tuberculosis  demonstration. 


■*WK 


